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PATIENT SAFETY INCIDENTS IN PROSTHODONTICS.

Byline: AYESHA ASLAM, ZEHRA IQTIDAR, BUSHRA REHMAN and AFSHEEN ALI

ABSTRACT

Patient safety can be defined as "the reduction of the risk of unnecessary harm associated with healthcare to an acceptable minimum". In contrast to medical healthcare, dentistry has somewhat lagged behind in developing and implementing advanced patient safety protocols. While developed countries have inculcated patient safety in their undergraduate and postgraduate dental curriculum, developing countries like ours still need to identify common preventable problems, record the frequency of such events and devise means to eliminate such incidents. This study aimed to report commonly encountered patient safety incidents in prosthodontics and their possible solutions.

A cross - sectional descriptive study using a self-administered questionnaire was used to collect data regarding the most common site of accidental injury during routine prosthodontic treatment, sources of injuries, commonly encountered medical emergencies, frequency of wrong site surgery and recommended measures to minimize patient safety incidents. Questionnaires were then distributed to 72 consultant and resident prosthodontists in eleven dental institutes in Punjab and KPK. Data was analyzed using SPSS version 21. Descriptive statistics were calculated. Majority (65%) of the prosthodontists agreed that dental patient safety incidents are often encountered in their routine practice but are never officially reported. Gingiva was the most frequent site of accidental injury while burs were the common source of injury.

Vasovagal syncope was the frequently encountered medical emergency (52%) while frequency of wrong site surgery was low (16%). Introduction of patient safety modules in curriculum, use of safety checklist, official reporting of patient safety incidents and continuing dental education programs on patient safety were the solutions favored by prosthodontists to minimize such incidents.

Key Words: Patient safety, dentistry, medical error, adverse events.

INTRODUCTION

Patient safety can be defined as "the reduction of the risk of unnecessary harm associated with healthcare to an acceptable minimum".1 A report published by US Institute of Medicine, titled "To Err is Human", revealed that more people in US died due to medical errors in provision of healthcare services than due to road traffic accidents, cancer or AIDS.2 Consequently, patient safety became the major concern in all healthcare services. This concern was further emphasized by WHO's "World Alliance on Patient Safety" program.3,4

Efforts aimed at improving patient safety and providing quality healthcare services have since been on the rise the world over.

In contrast to medical healthcare, dentistry has somewhat lagged behind in developing and implementing advanced patient safety protocols. Dental councils of developed countries have taken measures in the recent past to practice hazard - free dentistry and ensure patient safety.2 Implementation of these measures has its own share of difficulties. The General Council of Dentists of Spain reported a lack of data concerning adverse events in dentistry and emphasized the development of a risk management plan.5 National Patient Safety Agency (UK) also found a lack of incident reporting by dental surgery, orthodontics and pediatric dentistry.6

Patient safety protocols in developing countries are far from perfect. While developed countries have inculcated patient safety in their undergraduate and postgraduate curriculum, developing countries like ours still need to identify common preventable problems, record the frequency of such events and the factors contributing to them as well as to devise means to eliminate such incidents.7 Moreover, a habit to report patient safety incidents must be developed. This will help control such issues in future as well as forewarn colleagues and associates about possible risk.

This study aims to report the frequency of commonly encountered patient safety incidents in prosthodontics and their possible solutions. Data highlighting patient safety incidents in dentistry concerning the local population is scarce. This study may serve as a first step towards minimizing patient safety incidents and providing optimal dental care to the patients.

TABLE 1: FREQUENCY OF INVOLVEMENT OF INTRA-ORAL SITES IN ACCIDENTAL INJURY BY STUDY SUBJECTS DURING ROUTINE CLINICAL PRACTICE

Site of Injury###Frequency (N)###Relative Frequency (%)###Relative Cumulative Frequency

Lip###3###4.4###4.4

Gingivae###33###48.5###52.9

Tongue###12###17.6###70.6

Floor of the mouth###3###4.4###75

Adjacent tooth###14###20.6###95

Cheek (Intra - oral)###3###4.4###100

Total###68###100###100

TABLE 2: DENTAL SOURCES CAUSING ACCIDENTAL INJURIES DURING PROSTHODONTIC PRACTICE

Site of Injury###Frequency (N)###Relative Frequency (%)###Relative Cumulative Frequency

Burs###41###60.3###60.3

Sharp instruments###6###8.8###69.1

Local Anaesthesia###7###10.3###79.4

Burns from impression###13###19.1###98.5

compound

Others (e.g. impression###1###1.5###100

trays)

Total###68###100###100

TABLE 3: FREQUENCY OF OCCURRENCE OF COMMON MEDICAL EMERGENCIES DURING ROUTINE PROSTHODONTIC WORK

Medical Emergency###Frequency (N)###Relative Frequency (%)###Relative Cumulative Frequency

Vasovagal syncope###35###51.5###51.5

Hypoglycemia###16###23.5###75

Panic Attack###10###14.7###89.7

Angina###3###4.4###94.1

Uncontrolled bleeding###4###5.9###100

Total###68###100###100

METHODOLOGY

A cross - sectional descriptive study was designed and a self-administered close-ended questionnaire was used as the data collection tool. Questions were designed to assess the most common site of accidental injury during routine prosthodontic treatment, sources of accidental injuries, commonly encountered medical emergencies, frequency of wrong site surgery, any adverse reactions from materials and recommended measures to minimize patient safety incidents. Questionnaires were then distributed among 72 consultant and resident prosthodontists in eleven dental institutes in Punjab and KPK. Data was analyzed using SPSS version 21. Descriptive statistics were calculated.

TABLE 4: FREQUENCY OF WRONG SITE SURGERY (PREPARATION OF WRONG TOOTH) BY STUDY SUBJECTS IN ROUTINE PROSTHODONTIC PRACTICE

Is wrong site surgery###Frequency (N)###Relative Frequency###Relative Cumulative

frequently encountered?###(%)###Frequency

Yes###11###16.2###16.2

No###57###83.8###100

Total###68###100###100

TABLE 5: FREQUENCY OF OCCURRENCE AND REPORTING OF PATIENT SAFETY INCIDENTS BY STUDY SUBJECTS IN ROUTINE PROSTHODONTIC PRACTICE

Patient safety incidents###Frequency (N)###Relative Frequency (%)###Relative Cumula-

###tive Frequency

Occurrence###Always###1###1.5###1.5

###Often###44###64.7###66.2

###Seldom###12###17.6###83.8

###Never###11###16.2###100

###Always###--###--###--

###Often###--###--###--

Reporting###Seldom###--###--###--

###Never###--###100###100

TABLE 6: SOLUTIONS RECOMMENDED BY PROSTHODONTISTS TO MINIMIZE PATIENT SAFETY INCIDENTS

Possible Solution###Recommended###Frequency###Relative Fre-###Relative Cumula-

###(N)###quency (%)###tive Frequency

1. Using safety checklists###Yes###58###85.3###85.3

###No###10###14.7###100

###Total###68###100###100

2. Continuing dental education pro-###Yes###52###76.5###76.5

grams for clinicians###No###16###23.5###100

###Total###68###100###100

3. Working under supervision only###Yes###05###7.4###7.4

###No###63###92.6###93

###Total###68###100###100

4. Reporting patient safety incidents###Yes###47###69.1###69.1

###No###21###30.9###100

###Total###68###100###100

5. Including patient safety in un-###Yes###64###94.1###94.1

dergraduate and postgraduate cur-###No###4###5.9###100

riculum

###Total###68###100###100

RESULTS

Of the 72 distributed questionnaires, 68 were completely filled and returned yielding a response rate of 94%. In response to the question regarding the most common site of accidental injury during routine prosthodontic treatment, majority (48.5%) reported gingiva as the most common site, followed by adjacent tooth (20.6%) and tongue (17.6%) (Table 1). Most (60.3%) of respondents declared burs as the most common source of accidental injury (Table 2). Vasovagal syncope was found to be the frequently encountered medical emergency in prosthodontics followed by hypoglycemia (Table 3). Only 16% respondents admitted to preparing the wrong tooth during their practice (wrong site surgery) while all respondents affirmed no official reporting of patient safety incidents (Table 4, 5). Table 6 highlights the possible solutions to minimize patient safety incidents as recommended by study subjects.

DISCUSSION

This cross - sectional survey was conducted to highlight frequently encountered and yet preventable patient safety incidents in prosthodontics. Although medical and dental errors are inevitable to an extent8, most of them can be prevented if the clinician is equipped with appropriate knowledge and skill. This study, therefore, aims to report data regarding patient safety incidents which will make dental practitioners more aware of the possible risks and avoid such events in their setups.

In the present study, majority (48.5%) of the clinicians reported gingivae as the most site of accidental injury during routine prosthodontic procedures. Other common sites included the adjacent tooth (20.6%) and the tongue (17.6%). These findings are in contrast to those reported by Thusu et al.2 who reported lip as the commonest site of accidental injury (48%), followed by buccal gingiva (17%). This difference may be explained by the fact that protective measures such as the use of rubber dam and retraction cords by local dental practitioners is rather low9,10, resulting in increased risk of damage to soft tissues around the tooth being prepared.

The most common source of accidental injuries were burs used in high speed hand pieces (60.3%) followed by burns from impression compound (19.1%). These results are endorsed by those of Thusu et al.2 where burs accounted for 47% of the accidental injuries. The frequency of injuries due to local anesthetic (LA) use in the present study was 10.3% while that reported by Thusu et al.2 was 29.2%. This may be because LA is not routinely used in prosthodontic procedures as compared to oral surgical or endodontic procedures.

Medical emergency most frequently encountered by prosthodontists in the present survey was vasovagal syncope (51.5%) followed by hypoglycemia (23.5%). Similar findings have been reported by Thusu et al.2 However, a lower frequency of syncope (6%) was reported by Hivala et al.11 in the Finnish population. In response to question about frequency of wrong site surgery, 84% of the clinicians claimed it impossible to prepare a wrong tooth while 16% stated otherwise. The risk of wrong site surgery is greater with extractions as compared to prosthodontic rehabilitation.12 Although majority (64.7%) of the study subjects agreed that dental patient safety incidents occur often, all of the respondents declared that they had never officially reported any patient safety incident. In contrast, a study done in Finland found dental patient safety incidents reported by 84% of the dentists, although the incidents were of low severity.11

Lack of a reporting system in our healthcare system is an alarming situation and requires immediate action.

Regarding possible solutions to minimize patient safety incidents in prosthodontics, majority of the respondents favored the use of safety checklists and to investigate and report any patient safety incident that may occur. The clinicians also appreciated organization of continuing dental education programs regarding patient safety for all practicing dentists as well as to introduce patient safety modules in undergraduate and postgraduate curriculum. However, majority (92.6%) were not in favor of "working under supervision only". Similar response was reported by a study done in Karachi where 93% respondents wanted patient safety to be part of their curriculum and 90% were eager to learn how to report medical errors.8

While the present cross - sectional study may suffer from the risk of recall bias at the hands of the respondents, it may also be highlighted that such studies are rather hard to find in the literature. Studies reporting the incidence of patient safety events are few and far between. This makes comparison of results quite difficult. It is, however, hoped that the present study may serve as a base in highlighting the issue of dental patient safety incidents and encourage other researchers to broach this overlooked subject.

Dental profession is committed to providing safe dental care with minimum risk to the patients' health.13

However, with advancement in dental techniques and procedures, the risk of iatrogenic harm has also greatly increased. The need to establish and implement patient safety protocols cannot be overemphasized. Efforts need to be made to develop an open culture of patient safety where clinicians can learn from their own as well as from others' experiences.14

Accurate reporting and documentation of dental patient safety incidents must be encouraged.

CONCLUSIONS

Within the limitations of this study, the following conclusions can be drawn:

Majority (64.7%) of the prosthodontists agreed that dental patient safety incidents are often encountered in their routine practice but are never officially reported. Gingiva was the most frequent site of accidental injury while burs were the common source of such injuries. Vasovagal syncope was the frequently encountered medical emergency (51.5%) while frequency of wrong site surgery in prosthodontics was low (83.8%).

Majority of the respondents recommended the introduction of patient safety modules in curriculum, use of safety checklist, official reporting of patient safety incidents and continuing dental education programs on patient safety as possible means to minimize such incidents.

REFERENCES

1 Bailey E, Tickle M, Campbell S, O'Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health. 2015;15(1):152-68.

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3 Fletcher M, Hafner V. The World Alliance for Patient Safety. Ital J Public Health. 2012;2(3-4).

4 Sherman H, Castro G, Fletcher M, Hatlie M, Hibbert P, Jakob R, et al. Towards an International Classification for Patient Safety: the conceptual framework. International Journal for Quality in Health Care. 2009;21(1):2-8.

5 Perea-Perez B, Santiago-Saez A, Garcia-Marin F, Labajo-Gonzalez E, Villa-Vigil A. Patient safety in dentistry: dental care risk management plan. Med Oral Patol Oral Cir Bucal. 2011;16(6):e805-09.

6 Bagley CH, Panesar SS, Patel B, Cleary K, Pickles J. Safer cut: revelations of surgical harm through a national database. Br J Hosp Med (Lond). 2010;71(9):484-85.

7 Hafizullah M. Prioritizing patient safety in cardiology procedures. Pak Heart J. 2013;45(4):217-19.

8 Shah N, Jawaid M, Shah N, Ali SM. Patient Safety: perceptions of medical students of dow medical college, karachi. J Pak Med Assoc. 2015;65(12):1261-65.

9 Hassan SH, Aslam A, Khan DA. Impediments to the use of gingival retraction techniques. Pak Oral Dent J. 2016;36(3):487-91.

10 Ali A, Aslam A, Rehman B, Tariq A. Rubber dam use by general dental practitioners-prevalence and obstacles to its use. Pak Oral Dent J. 2016;36(3):468-71.

11 Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Patient safety incident prevention and management among Finnish dentists. Acta Odontol Scand. 2013;71(6):1663-70.

12 Taicher S. Wrong tooth extraction: Root cause analysis. Quintessence Int. 2010;41:869-72.

13 Pemberton M. Developing patient safety in dentistry. Br Dent J. 2014;217(7):335-37.

14 Yamalik N, Perea Perez B. Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J. 2012;62(4):189-96.
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Publication:Pakistan Oral and Dental Journal
Article Type:Report
Date:Mar 31, 2017
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